Provider Demographics
NPI:1871734186
Name:ROBERTS, JACQUE RAE (DC, LAC)
Entity type:Individual
Prefix:DR
First Name:JACQUE
Middle Name:RAE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 6TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2920
Mailing Address - Country:US
Mailing Address - Phone:503-635-7087
Mailing Address - Fax:
Practice Address - Street 1:470 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-2920
Practice Address - Country:US
Practice Address - Phone:503-635-7087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor